Case presentation

A 50-year-old man with history of a prior non-ST segment elevation myocardial infarction several years earlier presented with worsening angina and was referred for cardiac catheterization. Angina occured while walking less than 2 blocks and has increased in severity over the past year. Pain was promptly relieved by rest and occasionally required one or two sublingual nitroglycerin tablets for relief. Risk factors include ongoing, heavy tobacco abuse (three packs per day), hypertension, and dyslipidemia. His medications, with which he is admittedly poorly compliant, included lisinopril, metoprolol, simvastatin, isosorbide dinitrate, and aspirin. The physical examination was notable only for systolic hypertension, and a 12-lead electrocardiogram and routine blood studies were normal.

Cardiac catheterization

Left ventricular function was normal. Coronary angiography demonstrated complex and multivessel coronary disease. The right coronary artery was essentially totally occluded in the midportion with some anterograde flow (Figures 55-1, 55-2 and Videos 55-1, 55-2). Although the distal right coronary artery appeared small, the distal right coronary was believed to be larger, based on review of the prior angiogram and from the collateral visible from the left coronary artery (Figure 55-3). A long, moderate lesion was noted in the left anterior descending artery (LAD) (Figure 55-4) and the circumflex system appeared to be without significant stenosis (Figure 55-5). To determine the significance of the lesion, the operator further evaluated the LAD by assessing fractional flow reserve. Using a pressure wire and an intracoronary injection of adenosine to achieve maximum hyperemia, fractional flow reserve of the LAD was 0.69 and thus represented a significant lesion.

FIGURE 55-1 This is a left anterior oblique projection of the right coronary artery.

FIGURE 55-2 This is a right anterior oblique projection of the right coronary artery.

FIGURE 55-3 This angiogram shows the collateral to the right coronary artery (arrow).

FIGURE 55-4 A long, moderate stenosis was present in the left anterior descending artery (arrow) with a fractional flow reserve of 0.69, consistent with a significant stenosis.

FIGURE 55-5 This is a right anterior oblique projection with caudal angulation of the left coronary artery demonstrating no significant left circumflex disease.

The femoral artery sheath was removed and the patient brought to the recovery area. After discussing the options of surgical versus percutaneous revascularization, the patient chose a percutaneous approach and an elective procedure was scheduled for the following week.

He received 300 mg of clopidogrel the night before the procedure. The operator used bivalirudin as the procedural anticoagulant and began with the occluded right coronary artery. A floppy-tipped guidewire easily crossed the occluded segment and a 2.0 mm diameter compliant balloon was used to restore patency of the artery. The operator positioned and deployed two 2.5 mm diameter by 28 mm long sirolimus-eluting stents across the lesion. A residual stenosis remained in the proximal segment (Figure 55-6